While the rise of telehealth has brought us a plethora of advantages in the past two years, the concern of heightened fraud and abuse risks must not be overlooked. On July 20, 2022, the US Department of Health and Human Services Office of Inspector General issued a Special Fraud Alert (Alert) concerning the fraud and abuse risks associated with healthcare practitioners entering into arrangements with telemedicine companies.
The Alert follows several civil and criminal investigations into alleged fraud schemes involving companies that claimed to provide telehealth, telemedicine or telemarketing services but allegedly engaged in kickbacks and substandard medical practices to generate medically unnecessary orders and prescriptions for items or services, resulting in submissions of fraudulent claims to Medicare, Medicaid and other federal healthcare programs. The schemes generally involve telemedicine companies that contract with providers to order or prescribe medically unnecessary items and services for individuals who are solicited and recruited by such companies.
Common schemes may include telemedicine companies paying practitioners for ordering or prescribing items or services with respect to patients that were never examined for medical necessity. Providers should be on the lookout for the following suspect characteristics when entering into agreements with telemedicine companies:
- If patients are being identified or recruited by the telemedicine company through the advertisement of free or low out-of-pocket costs for items or services.
- If practitioners are not provided an opportunity to interact with patients or gather the information needed from patients to meaningfully assess them and determine the medical necessity of the prescribed items or services.
- If compensation paid to the practitioners takes into account the volume or value of items or services ordered or prescribed.
- If the telemedicine company only furnishes services to federal healthcare program beneficiaries and does not accept insurance from other payors.
- If the telemedicine company purports to provide services to individuals who are not federal healthcare program beneficiaries but actually bills federal healthcare programs.
- If the telemedicine company provides only one product or class of service, potentially restricting a practitioner’s treatment options to a predetermined course of treatment.
- The telemedicine company does not collect or provide information to enable or require practitioners to follow up with patients.
Overall, it is most important for providers to evaluate telemedicine arrangements to ensure compliance with fraud and abuse laws, to carefully review materials provided by the telemedicine company to ensure compliance with federal healthcare program coverage, to inquire about the telemedicine company’s clinical policies and procedures and to review patient-facing materials.
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